A surgeon made an incision in her chest and sawed through her breastbone.
That’s when the doctors discovered her heart was beating. She appeared to be breathing. They were slicing into Ms. Hawkins while she was alive.
Across the United States, an intricate system of hospitals, doctors and nonprofit donation coordinators carries out tens of thousands of lifesaving transplants each year. At every step, it relies on carefully calibrated protocols to protect both donors and recipients.
But in recent years, as the system has pushed to increase transplants, a growing number of patients have endured premature or bungled attempts to retrieve their organs. Though Ms. Hawkins’s case is an extreme example of what can go wrong, a New York Times examination revealed a pattern of rushed decision-making that has prioritized the need for more organs over the safety of potential donors.
In New Mexico, a woman was subjected to days of preparation for donation, even after her family said that she seemed to be regaining consciousness, which she eventually did. In Florida, a man cried and bit on his breathing tube but was still withdrawn from life support. In West Virginia, doctors were appalled when coordinators asked a paralyzed man coming off sedatives in an operating room for consent to remove his organs.
Stories like these have emerged as the transplant system has increasingly turned to a type of organ removal called donation after circulatory death. It accounted for a third of all donations last year: about 20,000 organs, triple the number from five years earlier.
Most donated organs in the United States come from people who are brain-dead — an irreversible state — and are kept on machines only to maintain their organs. Circulatory death donation is different. These patients are on life support, often in a coma. Their prognoses are more of a medical judgment call.
They are alive, with some brain activity, but doctors have determined that they are near death and won’t recover. If relatives agree to donation, doctors withdraw life support and wait for the patient’s heart to stop. This has to happen within an hour or two for the organs to be considered viable. After the person is declared dead, surgeons go in.
The Times found that some organ procurement organizations — the nonprofits in each state that have federal contracts to coordinate transplants — are aggressively pursuing circulatory death donors and pushing families and doctors toward surgery. Hospitals are responsible for patients up to the moment of death, but some are allowing procurement organizations to influence treatment decisions.
Workers in several states said they had seen coordinators persuading hospital clinicians to administer morphine, propofol and other drugs to hasten the death of potential donors.
Bryany Duff, a surgical technician in Colorado, said one patient, a middle-aged woman, was crying and looking around. But doctors sedated her and removed her from a ventilator, according to Ms. Duff and a former colleague.
In Miami in 2023, a potential donor who had broken his neck began crying and biting on his breathing tube, which a procurement organization worker said he interpreted as him not wanting to die. But clinicians sedated the patient, withdrew life support, waited for death and removed the organs, according to the worker and a colleague he told at the time.
In West Virginia, doctors were taken aback after Benjamin Parsons, a 27-year-old man paralyzed in a car accident, was brought to an operating room and asked to consent to donating his organs as he was coming off sedatives.
Communicating through blinks, he indicated that he did not give permission. Still, coordinators initially wanted to move forward, according to text messages and interviews.
The federal government increased oversight after an explosive House committee hearing last September.
The hearing was about the general performance of the transplant system, but was upended by testimony about the Kentucky man, who awoke just as he was about to be removed from life support in 2021. The man, Anthony Thomas Hoover, is still alive. He has neurological injuries and cannot recount what he experienced.
Mr. Hoover’s story shocked many people, but it sounded familiar to Danella Gallegos.
In 2022, when she was 38 and homeless, Ms. Gallegos was hospitalized and went into a coma. Doctors at Presbyterian Hospital in Albuquerque told her family she would never recover.
Her relatives agreed to donation, but as preparations began, they saw tears in her eyes. Their concerns were dismissed, according to interviews with the family and eight hospital workers. Donation coordinators said the tears were a reflex. (Tears can be an involuntary response to irritants.)
On the day of the planned donation, Ms. Gallegos was taken to a pre-surgery room, where her two sisters held her hands. A doctor arrived to withdraw life support. Then a sister announced she had seen Ms. Gallegos move. The doctor asked her to blink her eyes, and she complied. The room erupted in gasps.
Still, hospital workers said, the procurement organization wanted to move forward. A coordinator said it was just reflexes and suggested morphine to reduce movements. The hospital refused. Instead, workers brought her back to her room, and she made a full recovery.